Today, we discussed a case of an elderly woman with no known PMH who presented with new onset heart failure symptoms and recurrent syncope, found on arrival to have polymorphic VT. Her cardiac catheterization showed a complete occlusion of the LAD and circumflex, and she is undergoing a CABG today.
New-onset Heart Failure
Top 4 causes to consider in patients presenting with NEW-onset heart failure in the United States
- Ischemic heart disease
- Dilated cardiomyopathy (ischemia, alcohol, infections including HIV and viral myocarditis)
- Primary valvular heart disease
- Hypertensive heart disease
- Remember, ventricular tachycardia presents in 3 distinct patterns – monomorphic, pleomorphic, and polymorphic – Monomorphic: Single or unchanging morphology of all ventricular beats – Pleomorphic: QRS morphology is identical for several beats and then followed by a different QRS morphology for several beats – Polymorphic: QRS complex has changing morphologies with successive beats, often with irregular RR intervals
- Causes of Polymorphic VT
- Structural Heart Disease – Top cause: Ischemic heart disease – Non-ischemic cardiomyopathy
- Molecular or genetic abnormalities in ion channel function (Channelopathies) – Long QT syndrome – Short QT syndrome – Brugada syndrome – Early repolarization syndrome – Short-coupled torsade de pointes
- Other Acquired Causes – Electrolyte abnormalities – Drugs (QT prolonging medications) – Intracranial processes
Management of Ventricular Tachycardia
- Is the patient stable or unstable? If unstable, initiate ACLS protocol.
- If stable… – Assess via TTE to assess for structural abnormalities – Ensure that electrolytes are checked frequently and repleted – Evaluate all patients for ischemia as majority of patients with VT and structural heart disease have CAD – Remember the mortality benefit of AICD placement in patients with recurrent VT/VF – Antiarrhythmic drugs: We most commonly use Amiodarone (Class III antiarrhythmic) and Lidocaine (Class IB)